2018 ACLS Review – Asystole Case – Part 5 From The ACLS Manual

What follows are excerpts from the Asystole Case, pp 114 – 119 of the Advanced Cardiac Life Support Provider Manual c. 2016:


In this case the patient is in cardiac arrest. High-performance team members initiate and perform high-quality CPR throughout The BLS Assessment and The Primary And Secondary Assessments. The team interrupts CPR for 10 seconds or less for a rhythm check. The patient has no pulse and the rhythm on the monitor is asystole. Chest compressions resume immediately. The team leader now directs the team in the steps outlined in the asystole pathway of the Cardiac Arrest Algorithm beginning with Step 10.

IV/IO access is a priority over advanced airway management unless bag-mask ventilation is ineffective or the arrest is caused hypoxia. All high-performance team members must simultaneously conduct a search for an underlying and treatable cause of the asystole in addition to performing their assigned roles.

Rhythms for Asystole

  • Asystole
  • Slow PEA terminating in bradysystolic arrythmia

Introduction To Asystole

  • Asystole is a cardiac arrest rhythm associated with no discernible electrical activity on the ECG (also referred to as flat line). You should confirm that the flat line on the monitor is indeed “true asystole ” by validating that the flat line is:
    • Not another rhthm (eg, fine VF) masquerading as a flat line
    • Not the result of an operator error

Asystole and Technical Problems

For a patient with cardiac arrest and asystole, quickly rule out any other causes of an isoelectric ECG such as:

  • Loose leads or leads not connected to the patient or defibrillator/monitor
  • No power
  • Signal gain (amplitude/signal strength) too low

Asystole: An Agonal Rhythm?

You will see asystole most frequently in 2 situations:

  • As a terminal rhythm in a resuscitation attempt that started with another rhythm
  • As the first rhythm identified in a  patient with unwitnessed or prolonged arrest

Persistent asystole represents extensive myocardial ischemia and damage from prolonged periods of inadequate coronary perfusion. Prognosis is poor unless a special resuscitative circumstance or immediately reversible cause is present. Survival from asystole is better for in-hospitalthan for out-of-hospital  arrests. . .

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